The pre-school child with chronic cough

This sweet little girl shows the viewer the correct way to sneeze or cough by using the inside of her elbow and not her hands.
This sweet little girl shows the viewer the correct way to sneeze or cough by using the inside of her elbow and not her hands.

Dr Kevin Gruffydd-Jones describes a case of a child with persistent cough and discusses the causes of chronic cough in children

Key learning points

  • Cough is a very common complaint in children presenting to general practice
  • Most coughs resolve within three weeks
  • Causes of persistent cough in children include post-viral infection, foreign bodies, asthma and protracted bacterial bronchitis

Introduction

Cough is a very common complaint in children presenting to general practice. Cough without colds has a reported prevalence of 28% of boys and 30% of girls.1 Most coughs resolve within three weeks but persistent cough in children can present a diagnostic dilemma.

Case study

Lucy is a two-year-old girl whose asthmatic mother brought her to the surgery with ‘yet another cough’. She had several visits to the surgery over the previous few months with a ‘fruity’ cough, which was worse at night. The cough had persisted despite two courses of amoxicillin and she was on a salbutamol inhaler as needed, given via a large volume spacer device, as there was mention once that Lucy had wheezed on one occasion at night.

Lucy appeared to be growing normally on the centile chart. The mother wanted to know whether Lucy had asthma.

On examination Lucy looked generally well, was not breathless, was apyrexial and had bilateral basal crackles on auscultation of her chest.

Discussion

Causes of persistent cough are as follows:

Post-viral. This is the most common cause. Ninety per cent of post-viral coughs will resolve within three weeks although 20% of children suffering from respiratory syncytial virus (RSV) associated bronchiolitis may still have a cough after four weeks.

A diagnosis of pertussis should be considered, especially in the presence (but not exclusively) of ‘whoop’ or post-tussive vomiting. The median duration of cough is around 11 days.2

Foreign body. The presence of an inhaled foreign body should be considered in the young child with chronic cough especially where there is asymmetric air entry in the lungs.

‘Red flag’ features. The following features should raise the possibility of more severe disease:

Fever: recurrent/persistent pneumonia, TB;

Failure to thrive: TB, cystic fibrosis;

Neonatal cough: TB, cystic fibrosis, congenital abnormalities.

Asthma. Unlike in adults, a diagnosis of asthma in a child with persistent/recurrent cough in the absence of wheeze is unlikely. There is poor concordance between health professionals about what constitutes a ‘wheeze’. This might need to be demonstrated!

In a child under five with cough and wheeze, a past or family history of atopic disease with symptoms occurring in the presence of multiple triggers (including exercise, viral infections, dust and pollen) suggests asthma. This is further supported by a positive symptomatic response to a 6–8 week trial of inhaled corticosteroid therapy (400 microgram beclometasone equivalent per day).

Protracted bacterial bronchitis (PBB). A European Respiratory Society task force document states that a diagnosis of PBB should be made where:3

  • There is a persistent (more than four weeks) wet or productive cough.
  • An absence of symptoms of signs to suggest an alternative diagnosis.
  • The cough resolves after a 2–4 week course of a ‘suitable antibiotic’.
  • The recommended antibiotic is co-amoxiclav (or a macrolide if penicillin resistant).

Lucy’s progress

On further questioning, the reported ‘wheeze’ was in fact a cough variation and there was no evidence of a pattern of coughing with trigger factors. The presence of a persistent fruity cough and bilateral basal crackles in the absence of other signs made a diagnosis of protracted bacterial bronchitis likely and she dramatically improved with a two-week course of co-amoxiclav.

 

This article was initiated and funded by Teva Respiratory. Teva have had no influence over content and the aforementioned trails. Topics and content have been selected and written by independent experts.


References
  1. Shields MD, Bush A, et al. Thorax 2008;63 Suppl 3:iii1-iii15.
  2. Shields MD, Thavagnanam S. Cough 2003;9(1):11.
  3. Kantar A, Chang AB, et al. European Respiratory Journal 2017;50(2):pii:1602139.

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